|
INDIUM 111 - IN PENTETREOTIDE
|
Facility
|
OP
|
$1,414.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
34000071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$183.82 |
| Max. Negotiated Rate |
$1,357.44 |
| Rate for Payer: Aetna Commercial |
$1,088.78
|
| Rate for Payer: Anthem Medicaid |
$486.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,102.92
|
| Rate for Payer: Cash Price |
$707.00
|
| Rate for Payer: Cigna Commercial |
$1,173.62
|
| Rate for Payer: First Health Commercial |
$1,343.30
|
| Rate for Payer: Humana Commercial |
$1,201.90
|
| Rate for Payer: Humana KY Medicaid |
$486.27
|
| Rate for Payer: Kentucky WC Medicaid |
$491.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,159.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,043.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$424.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$496.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,244.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,060.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$282.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$183.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.34
|
| Rate for Payer: PHCS Commercial |
$1,357.44
|
| Rate for Payer: United Healthcare All Payer |
$1,244.32
|
|
|
INDIUM 111 - IN PENTETREOTIDE
|
Professional
|
Both
|
$1,414.00
|
|
| Hospital Charge Code |
34000071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$494.90 |
| Max. Negotiated Rate |
$1,414.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,414.00
|
| Rate for Payer: Cash Price |
$707.00
|
| Rate for Payer: Multiplan PHCS |
$848.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$989.80
|
| Rate for Payer: UHCCP Medicaid |
$494.90
|
|
|
INDIUM 111 - IN PENTETREOTID(T
|
Facility
|
IP
|
$1,414.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
340T0071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$183.82 |
| Max. Negotiated Rate |
$1,357.44 |
| Rate for Payer: Aetna Commercial |
$1,088.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,102.92
|
| Rate for Payer: Cash Price |
$707.00
|
| Rate for Payer: Cigna Commercial |
$1,173.62
|
| Rate for Payer: First Health Commercial |
$1,343.30
|
| Rate for Payer: Humana Commercial |
$1,201.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,159.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,043.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$424.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,244.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,060.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$282.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$183.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.34
|
| Rate for Payer: PHCS Commercial |
$1,357.44
|
| Rate for Payer: United Healthcare All Payer |
$1,244.32
|
|
|
INDIUM 111 - IN PENTETREOTID(T
|
Facility
|
OP
|
$1,414.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
340T0071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$183.82 |
| Max. Negotiated Rate |
$1,357.44 |
| Rate for Payer: Aetna Commercial |
$1,088.78
|
| Rate for Payer: Anthem Medicaid |
$486.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,102.92
|
| Rate for Payer: Cash Price |
$707.00
|
| Rate for Payer: Cigna Commercial |
$1,173.62
|
| Rate for Payer: First Health Commercial |
$1,343.30
|
| Rate for Payer: Humana Commercial |
$1,201.90
|
| Rate for Payer: Humana KY Medicaid |
$486.27
|
| Rate for Payer: Kentucky WC Medicaid |
$491.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,159.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,043.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$424.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$496.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,244.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,060.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$282.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$183.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.34
|
| Rate for Payer: PHCS Commercial |
$1,357.44
|
| Rate for Payer: United Healthcare All Payer |
$1,244.32
|
|
|
INDIUM IN-111 AUTOLOGOUS WBCEL
|
Facility
|
IP
|
$6,566.00
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
340T0070
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$853.58 |
| Max. Negotiated Rate |
$6,303.36 |
| Rate for Payer: Aetna Commercial |
$5,055.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,121.48
|
| Rate for Payer: Cash Price |
$3,283.00
|
| Rate for Payer: Cigna Commercial |
$5,449.78
|
| Rate for Payer: First Health Commercial |
$6,237.70
|
| Rate for Payer: Humana Commercial |
$5,581.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,384.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,845.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,969.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,778.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,924.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,313.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$853.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,035.46
|
| Rate for Payer: PHCS Commercial |
$6,303.36
|
| Rate for Payer: United Healthcare All Payer |
$5,778.08
|
|
|
INDIUM IN-111 AUTOLOGOUS WBCEL
|
Professional
|
Both
|
$6,566.00
|
|
| Hospital Charge Code |
34000070
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$2,298.10 |
| Max. Negotiated Rate |
$6,566.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$6,566.00
|
| Rate for Payer: Cash Price |
$3,283.00
|
| Rate for Payer: Multiplan PHCS |
$3,939.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,596.20
|
| Rate for Payer: UHCCP Medicaid |
$2,298.10
|
|
|
INDIUM IN-111 AUTOLOGOUS WBCEL
|
Facility
|
IP
|
$6,566.00
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
34000070
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$853.58 |
| Max. Negotiated Rate |
$6,303.36 |
| Rate for Payer: Aetna Commercial |
$5,055.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,121.48
|
| Rate for Payer: Cash Price |
$3,283.00
|
| Rate for Payer: Cigna Commercial |
$5,449.78
|
| Rate for Payer: First Health Commercial |
$6,237.70
|
| Rate for Payer: Humana Commercial |
$5,581.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,384.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,845.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,969.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,778.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,924.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,313.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$853.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,035.46
|
| Rate for Payer: PHCS Commercial |
$6,303.36
|
| Rate for Payer: United Healthcare All Payer |
$5,778.08
|
|
|
INDIUM IN-111 AUTOLOGOUS WBCEL
|
Facility
|
OP
|
$6,566.00
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
34000070
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$853.58 |
| Max. Negotiated Rate |
$6,303.36 |
| Rate for Payer: Aetna Commercial |
$5,055.82
|
| Rate for Payer: Anthem Medicaid |
$2,258.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,121.48
|
| Rate for Payer: Cash Price |
$3,283.00
|
| Rate for Payer: Cigna Commercial |
$5,449.78
|
| Rate for Payer: First Health Commercial |
$6,237.70
|
| Rate for Payer: Humana Commercial |
$5,581.10
|
| Rate for Payer: Humana KY Medicaid |
$2,258.05
|
| Rate for Payer: Kentucky WC Medicaid |
$2,281.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,384.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,845.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,969.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,303.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,778.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,924.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,313.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$853.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,035.46
|
| Rate for Payer: PHCS Commercial |
$6,303.36
|
| Rate for Payer: United Healthcare All Payer |
$5,778.08
|
|
|
INDIUM IN-111 AUTOLOGOUS WBCEL
|
Facility
|
OP
|
$6,566.00
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
340T0070
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$853.58 |
| Max. Negotiated Rate |
$6,303.36 |
| Rate for Payer: Aetna Commercial |
$5,055.82
|
| Rate for Payer: Anthem Medicaid |
$2,258.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,121.48
|
| Rate for Payer: Cash Price |
$3,283.00
|
| Rate for Payer: Cigna Commercial |
$5,449.78
|
| Rate for Payer: First Health Commercial |
$6,237.70
|
| Rate for Payer: Humana Commercial |
$5,581.10
|
| Rate for Payer: Humana KY Medicaid |
$2,258.05
|
| Rate for Payer: Kentucky WC Medicaid |
$2,281.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,384.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,845.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,969.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,303.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,778.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,924.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,313.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$853.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,035.46
|
| Rate for Payer: PHCS Commercial |
$6,303.36
|
| Rate for Payer: United Healthcare All Payer |
$5,778.08
|
|
|
INDIUM WBC LABELING
|
Facility
|
IP
|
$828.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
34000043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$107.64 |
| Max. Negotiated Rate |
$794.88 |
| Rate for Payer: Aetna Commercial |
$637.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$645.84
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$687.24
|
| Rate for Payer: First Health Commercial |
$786.60
|
| Rate for Payer: Humana Commercial |
$703.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$678.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$611.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$248.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$728.64
|
| Rate for Payer: Ohio Health Group HMO |
$621.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$165.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$256.68
|
| Rate for Payer: PHCS Commercial |
$794.88
|
| Rate for Payer: United Healthcare All Payer |
$728.64
|
|
|
INDIUM WBC LABELING
|
Facility
|
OP
|
$828.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
34000043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$107.64 |
| Max. Negotiated Rate |
$794.88 |
| Rate for Payer: Aetna Commercial |
$637.56
|
| Rate for Payer: Anthem Medicaid |
$284.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$645.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cigna Commercial |
$687.24
|
| Rate for Payer: First Health Commercial |
$786.60
|
| Rate for Payer: Humana Commercial |
$703.80
|
| Rate for Payer: Humana KY Medicaid |
$284.75
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$287.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$678.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$611.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$290.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$728.64
|
| Rate for Payer: Ohio Health Group HMO |
$621.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$165.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$256.68
|
| Rate for Payer: PHCS Commercial |
$794.88
|
| Rate for Payer: United Healthcare All Payer |
$728.64
|
|
|
INDIUM WBC LABELING
|
Professional
|
Both
|
$828.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
34000043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$828.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$828.00
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$496.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$579.60
|
| Rate for Payer: UHCCP Medicaid |
$289.80
|
|
|
INDIUM WBC LABELING(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
340P0043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
|
|
INDIUM WBC LABELING(T
|
Facility
|
OP
|
$678.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
340T0043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$88.14 |
| Max. Negotiated Rate |
$650.88 |
| Rate for Payer: Aetna Commercial |
$522.06
|
| Rate for Payer: Anthem Medicaid |
$233.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$356.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$528.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$499.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$481.49
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Cigna Commercial |
$562.74
|
| Rate for Payer: First Health Commercial |
$644.10
|
| Rate for Payer: Humana Commercial |
$576.30
|
| Rate for Payer: Humana KY Medicaid |
$233.16
|
| Rate for Payer: Humana Medicare Advantage |
$356.66
|
| Rate for Payer: Kentucky WC Medicaid |
$235.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$555.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$500.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$427.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$237.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$596.64
|
| Rate for Payer: Ohio Health Group HMO |
$508.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.18
|
| Rate for Payer: PHCS Commercial |
$650.88
|
| Rate for Payer: United Healthcare All Payer |
$596.64
|
|
|
INDIUM WBC LABELING(T
|
Facility
|
IP
|
$678.00
|
|
|
Service Code
|
HCPCS 78999
|
| Hospital Charge Code |
340T0043
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$88.14 |
| Max. Negotiated Rate |
$650.88 |
| Rate for Payer: Aetna Commercial |
$522.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$528.84
|
| Rate for Payer: Cash Price |
$339.00
|
| Rate for Payer: Cigna Commercial |
$562.74
|
| Rate for Payer: First Health Commercial |
$644.10
|
| Rate for Payer: Humana Commercial |
$576.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$555.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$500.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$203.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$596.64
|
| Rate for Payer: Ohio Health Group HMO |
$508.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.18
|
| Rate for Payer: PHCS Commercial |
$650.88
|
| Rate for Payer: United Healthcare All Payer |
$596.64
|
|
|
INDIVIDUAL EXERCISE EA 15 MIN
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
41000098
|
|
Hospital Revenue Code
|
419
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
INDIVIDUAL EXERCISE EA 15 MIN
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
HCPCS 97110
|
| Hospital Charge Code |
41000098
|
|
Hospital Revenue Code
|
419
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$140.16 |
| Rate for Payer: Aetna Commercial |
$112.42
|
| Rate for Payer: Anthem Medicaid |
$50.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.88
|
| Rate for Payer: Cash Price |
$73.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: First Health Commercial |
$138.70
|
| Rate for Payer: Humana Commercial |
$124.10
|
| Rate for Payer: Humana KY Medicaid |
$50.21
|
| Rate for Payer: Kentucky WC Medicaid |
$50.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$119.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$51.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$128.48
|
| Rate for Payer: Ohio Health Group HMO |
$109.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.26
|
| Rate for Payer: PHCS Commercial |
$140.16
|
| Rate for Payer: United Healthcare All Payer |
$128.48
|
|
|
INDOCIN 50 MG SUPP
|
Facility
|
OP
|
$531.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.15 |
| Max. Negotiated Rate |
$510.63 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.89
|
| Rate for Payer: Cash Price |
$265.96
|
| Rate for Payer: Cigna Commercial |
$441.49
|
| Rate for Payer: First Health Commercial |
$505.31
|
| Rate for Payer: Humana Commercial |
$452.12
|
| Rate for Payer: Humana KY Medicaid |
$182.92
|
| Rate for Payer: Kentucky WC Medicaid |
$184.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$436.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$392.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$468.08
|
| Rate for Payer: Ohio Health Group HMO |
$398.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$164.89
|
| Rate for Payer: PHCS Commercial |
$510.63
|
| Rate for Payer: United Healthcare All Payer |
$468.08
|
| Rate for Payer: Aetna Commercial |
$409.57
|
| Rate for Payer: Anthem Medicaid |
$182.92
|
|
|
INDOCIN 50 MG SUPP
|
Facility
|
IP
|
$531.91
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.15 |
| Max. Negotiated Rate |
$510.63 |
| Rate for Payer: Aetna Commercial |
$409.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.89
|
| Rate for Payer: Cash Price |
$265.96
|
| Rate for Payer: Cigna Commercial |
$441.49
|
| Rate for Payer: First Health Commercial |
$505.31
|
| Rate for Payer: Humana Commercial |
$452.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$436.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$392.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$468.08
|
| Rate for Payer: Ohio Health Group HMO |
$398.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$164.89
|
| Rate for Payer: PHCS Commercial |
$510.63
|
| Rate for Payer: United Healthcare All Payer |
$468.08
|
|
|
INDOCIN (INDOMETHACI 25MG/1CAP
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
25000779
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
INDOCIN (INDOMETHACI 25MG/1CAP
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
25000779
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
INDOCYANINE GREEN 25MG VIAL
|
Facility
|
IP
|
$563.83
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
25003124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.30 |
| Max. Negotiated Rate |
$541.28 |
| Rate for Payer: Aetna Commercial |
$434.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$439.79
|
| Rate for Payer: Cash Price |
$281.92
|
| Rate for Payer: Cigna Commercial |
$467.98
|
| Rate for Payer: First Health Commercial |
$535.64
|
| Rate for Payer: Humana Commercial |
$479.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$462.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$496.17
|
| Rate for Payer: Ohio Health Group HMO |
$422.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$174.79
|
| Rate for Payer: PHCS Commercial |
$541.28
|
| Rate for Payer: United Healthcare All Payer |
$496.17
|
|
|
INDOCYANINE GREEN 25MG VIAL
|
Facility
|
OP
|
$563.83
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
25003124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.30 |
| Max. Negotiated Rate |
$541.28 |
| Rate for Payer: Aetna Commercial |
$434.15
|
| Rate for Payer: Anthem Medicaid |
$193.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$439.79
|
| Rate for Payer: Cash Price |
$281.92
|
| Rate for Payer: Cigna Commercial |
$467.98
|
| Rate for Payer: First Health Commercial |
$535.64
|
| Rate for Payer: Humana Commercial |
$479.26
|
| Rate for Payer: Humana KY Medicaid |
$193.90
|
| Rate for Payer: Kentucky WC Medicaid |
$195.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$462.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$197.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$496.17
|
| Rate for Payer: Ohio Health Group HMO |
$422.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$174.79
|
| Rate for Payer: PHCS Commercial |
$541.28
|
| Rate for Payer: United Healthcare All Payer |
$496.17
|
|
|
INFANRIX VACC (DTAP) 0.5ML
|
Facility
|
IP
|
$182.55
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
25000035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.73 |
| Max. Negotiated Rate |
$175.25 |
| Rate for Payer: Aetna Commercial |
$140.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.39
|
| Rate for Payer: Cash Price |
$91.28
|
| Rate for Payer: Cigna Commercial |
$151.52
|
| Rate for Payer: First Health Commercial |
$173.42
|
| Rate for Payer: Humana Commercial |
$155.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$149.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$160.64
|
| Rate for Payer: Ohio Health Group HMO |
$136.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.59
|
| Rate for Payer: PHCS Commercial |
$175.25
|
| Rate for Payer: United Healthcare All Payer |
$160.64
|
|
|
INFANRIX VACC (DTAP) 0.5ML
|
Facility
|
OP
|
$182.55
|
|
|
Service Code
|
HCPCS 90700
|
| Hospital Charge Code |
25000035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.73 |
| Max. Negotiated Rate |
$175.25 |
| Rate for Payer: Aetna Commercial |
$140.56
|
| Rate for Payer: Anthem Medicaid |
$62.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.39
|
| Rate for Payer: Cash Price |
$91.28
|
| Rate for Payer: Cigna Commercial |
$151.52
|
| Rate for Payer: First Health Commercial |
$173.42
|
| Rate for Payer: Humana Commercial |
$155.17
|
| Rate for Payer: Humana KY Medicaid |
$62.78
|
| Rate for Payer: Kentucky WC Medicaid |
$63.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$149.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$160.64
|
| Rate for Payer: Ohio Health Group HMO |
$136.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.59
|
| Rate for Payer: PHCS Commercial |
$175.25
|
| Rate for Payer: United Healthcare All Payer |
$160.64
|
|
